Home Members Only Join/Renew Contact Us JobMart

Membership Application

3 Easy Ways to Apply
Phone 847/375-4712 Mon-Fri, 9 am - 5 pm CDT (credit card payment only)	Fax 877/734-8671 (credit card payment only)	Mail AAHPM PO Box 3781 Oak Brook, IL 60522

Please print this form, complete it, and use it when calling to join over the phone (for credit card payments), or when mailing or faxing.

Name
Credentials
Title
Office/Facility
Hospice Affiliation
Preferred mailing address	Office Home Hospice
Street address
City/State/Zip
Telephone	Home Work
	()
Fax	()
E-mail

Membership Type (Choose one)
Physician ($325)	Affiliate ($160)	Fellow* ($100)	Resident/Student** ($0)	International Corresponding*** ($0)
* Documentation must be provided from the current fellowship program director.
** Residents and medical/nursing students are entitled to a free, virtual membership with documentation from the dean of a current program. Virtual membership provides electronic access only to periodicals.
*** International Corresponding membership is available to physicians at the postgraduate level for whom a significant portion of their professional activity is related to palliative care, and who reside in a nation included on the HINARI lists of eligible countries (www.who.int/hinari/eligibility/en/). Applicants must provide documentation that they reside in an eligible country. International Corresponding members receive electronic access only to periodicals and may not vote, hold office, or serve on AAHPM committees or task forces.

Are you
Salaried	Volunteer

Work
Part Time	Full Time

If you would like to join one of AAHPM's special interest groups, please indicate below:
Ethics	Heart Failure	Humanities
Long Term Care	Pediatric	Rural
Professionals in Training	Osteopathic

Payment

MasterCard

VISA

AMEX

Check enclosed (made payable to AAHPM)

• IF YOU FAX THIS FORM, PLEASE DO NOT MAIL THE ORIGINAL.
• If rebilling of a credit card charge is necessary, a $25 processing fee will be charged.
• Checks not in U.S. funds will be returned. A charge of $20 will apply to checks returned for insufficient funds.

Account number

Expiration date

Signature

Cardholder’s name (Please print.)

Membership dues may be deductible as an ordinary business expense. Consult your tax adviser for information.